1/120. Purulent pericarditis misdiagnosed as septic shock.BACKGROUND: Septic shock is common, with approximately 200,000 cases recognized annually. This syndrome is so well characterized that when a patient is febrile and in shock, septic shock may be diagnosed without regard to alternative possibilities. Purulent pericarditis is a relatively rare disorder in which fever and hypotension are common. Classic signs and symptoms, such as chest pain, pericardial friction rub, pulsus paradoxus, and elevation of jugular venous pressure, are seen in only 50%. methods: In this report, we describe four patients in whom purulent pericarditis and pericardial tamponade was initially misdiagnosed as septic shock. During a 3-month period, three men and one woman (mean age, 44.5 years) came to Kern Medical Center with purulent pericarditis and pericardial tamponade. These cases represented 13% of patients admitted with a diagnosis of septic shock. RESULTS: All patients were bacteremic, and the classic findings of pericardial tamponade were absent or relatively subtle. Hemodynamic findings of elevated systemic vascular resistance, low cardiac output, and normal pulmonary artery occlusion pressure were critical to the diagnosis. CONCLUSIONS: Consideration of purulent pericarditis is important in cases diagnosed as septic shock. Clinicians should be aware that patients with purulent pericarditis may not exhibit classic signs and symptoms, and a high index of suspicion is necessary for appropriate management.- - - - - - - - - - ranking = 1keywords = chest pain, chest, pain (Clic here for more details about this article) |
2/120. hypothyroidism presenting as acute cardiac tamponade with viral pericarditis.This report describes the case of a young woman who presented to an emergency department with severe abdominal pain and shock. The patient was found to have pericardial tamponade due to a massive pericardial effusion. On further evaluation, the etiology of this effusion was considered to be secondary to hypothyroidism with concominant acute viral pericarditis leading to a fulminant tamponade. The presentation, differential diagnosis, and management of pericardial effusion and tamponade secondary to hypothyroidism and viral pericarditis are discussed. The diagnosis of hypothyroidism in conjunction with acute viral pericarditis should be considered in patients presenting with unexplained pericardial effusion and tamponade.- - - - - - - - - - ranking = 0.0024746512181604keywords = pain (Clic here for more details about this article) |
3/120. Primary right atrial angiosarcoma mimicking acute pericarditis, pulmonary embolism, and tricuspid stenosis.A 29 year old white man presented to the emergency room with new onset pleuritic chest pain and shortness of breath. He was initially diagnosed as having viral pericarditis and was treated with non-steroidal anti-inflammatory drugs. A few weeks later he developed recurrent chest pain with cough and haemoptysis. Chest radiography, cardiac examination, transthoracic and transoesophageal echocardiography pointed to a mass that arose from the posterior wall of the right atrium, not attached to the interatrial septum, which protruded into the lumen of the right atrium causing intermittent obstruction of inflow across the tricuspid valve. Contrast computed tomography of the chest showed a right atrial mass extending to the anterior chest wall. The lung fields were studded with numerous pulmonary nodules suggestive of metastases. A fine needle aspiration of the pulmonary nodule revealed histopathology consistent with spindle cell sarcoma thought to originate in the right atrium. Immunohistochemical stains confirmed that this was an angiosarcoma. There was no evidence of extracardiac origin of the tumour. The patient was treated with chemotherapy and radiation. This case highlights the clinical presentation, rapid and aggressive course of cardiac angiosarcomas, and the diagnostic modalities available for accurate diagnosis.- - - - - - - - - - ranking = 2.0595053994341keywords = chest pain, chest, pain (Clic here for more details about this article) |
4/120. Serosal complications of single-agent low-dose methotrexate used in gestational trophoblastic diseases: first reported case of methotrexate-induced peritonitis.methotrexate (MTX) is a folate antagonist widely used both as an anticancer drug and as an immunosupressant. Administration of an 8-day methotrexate and folinic acid regime may be associated with pleuritic chest pain and pneumonitis. We have reviewed the toxicity seen in 168 consecutive patients treated with low-dose MTX for persistent trophoblastic disease. Twenty-five per cent of patients developed serosal symptoms, pleurisy was the commonest complaint. The majority of patients had mild to moderate symptoms which were controlled with simple analgesia and did not necessitate a change in treatment; 11.9% had severe symptoms which necessitated a change in treatment. One patient developed a pericardial effusion and a second patient developed severe reversible peritoneal irritation. The possible aetiology and pathophysiology of methotrexate-induced serosal toxicity is discussed.- - - - - - - - - - ranking = 1keywords = chest pain, chest, pain (Clic here for more details about this article) |
5/120. Purulent pericarditis due to group B streptococcus and mycotic aneurysm of the ascending aorta: case report.A 61-year-old female, with a history of uterine and cervical cancer treated with radical hysterectomy and 2 years of postoperative chemotherapy, presented to the emergency department with dyspnea on exertion. Computed tomography of the chest revealed a large pericardial effusion and a sacciform aneurysm of the ascending aorta. The patient subsequently underwent emergency pericardiocentesis with drainage of approximately 330 ml of a bloody and turbid effusion. Cultures from the effusion yielded group B streptococcus. multiple organ failure and disseminated intravascular coagulation syndrome occurred in the acute phase, but gradually improved with continuous antibiotic therapy. On the 194th hospital day, in situ reconstruction of the ascending aorta was successfully performed using a synthetic graft. Although rarely reported, both purulent bacterial pericarditis and mycotic aneurysm can be life-threatening.- - - - - - - - - - ranking = 0.029752699717071keywords = chest (Clic here for more details about this article) |
6/120. Drug induced chest pain-rare but important.pericarditis, usually viral in origin, is an infrequent cause of chest pain. pericarditis due to drug allergy is even less frequent and is thus rarely considered in the differential diagnosis. A case is reported of a woman who presented with severe chest pain, caused by minocycline induced pericarditis. Such allergy may be more common than reported. It is suggested that drug induced pericarditis should be included in the differential diagnosis of acute chest pain.- - - - - - - - - - ranking = 7keywords = chest pain, chest, pain (Clic here for more details about this article) |
7/120. Recurrent pericarditis after thoracic surgery.Acute pericarditis is a frequent complication after cardiac and/or thoracic surgery. Recurrent acute pericarditis with multiple episodes is an uncommon phenomenon, however. patients typically have chest pain and/or pericardial inflammation as shown by electrocardiography and echocardiography. Treatment presents a clinical challenge due to the condition's rarity and lack of multicenter comparative treatment studies. Numerous therapeutic modalities, including nonsteroidal anti-inflammatory agents (NSAIDs), corticosteroids, immunosuppressants, and pericardiectomy, have been used without overwhelming evidence of a standard protocol. We report a case in which 32 episodes of recurrent acute pericarditis occurred, emphasizing the need for multicenter trials comparing therapeutic modalities in the future.- - - - - - - - - - ranking = 1keywords = chest pain, chest, pain (Clic here for more details about this article) |
8/120. Electrocardiographic ST-segment elevation: correct identification of acute myocardial infarction (AMI) and non-AMI syndromes by emergency physicians.OBJECTIVE: To determine the emergency physician's (EP's) ability to identify the cause of ST-segment elevation (STE) in a hypothetical chest pain patient. methods: Eleven electrocardiograms (ECGs) with STE were given to EPs; the patient in each instance was a 45-year-old male with a medical history of hypertension and diabetes mellitus with the chief complaint of chest pain. The EP was asked to determine the cause of the STE and, if due to acute myocardial infarction (AMI), to decide whether thrombolytic therapy (TT) would be administered (the patient had no contraindication to such treatment). Rates of TT administration were determined; appropriate TT administration was defined as that occurring in an AMI patient, while inappropriate TT administration was defined as that in the non-AMI patient. RESULTS: Four hundred fifty-eight EPs completed the questionnaire; levels of medical experience included the following: postgraduate year 2-3, 193 (42%); and attending, 265 (58%). The overall rate of correct interpretation of the study ECGs was 94.9% (4,782 correct interpretations out of 5,038 instances). Acute myocardial infarction with typical STE, ventricular paced rhythm, and right bundle branch block were never misinterpreted. The remaining conditions were misinterpreted with rates ranging between 9% (left bundle branch block, LBBB) and 72% (left ventricular aneurysm, LVA). The overall rate of appropriate thrombolytic agent administration was 83% (1,525 correct administrations out of 1,832 indicated administrations). The leading diagnosis for which thrombolytic agent was given inappropriately was LVA (28%), followed by benign early repolarization (23%), pericarditis (21%), and LBBB without electrocardiographic AMI (5%). Thrombolytic agent was appropriately given in all cases of AMI except when associated with atypical STE, where it was inappropriately withheld 67% of the time. CONCLUSIONS: In this survey, EPs were asked whether they would give TT based on limited information (ECG). Certain syndromes with STE were frequently misdiagnosed. Emergency physician electrocardiographic education must focus on the proper identification of these syndromes so that TT may be appropriately utilized.- - - - - - - - - - ranking = 2keywords = chest pain, chest, pain (Clic here for more details about this article) |
9/120. pericarditis presenting and treated as an acute anteroseptal myocardial infarction.Early recognition and treatment of acute myocardial infarctions have been accepted as improving patient mortality. With the popular use of thrombolytic therapy, it is necessary to rule out contraindications and to consider other causes for ST segment elevation. A unique patient experiencing chest pain with marked and localized ST segment elevation in the anteroseptal leads is presented. He was treated with thrombolytic therapy. Subsequent investigations ruled out the diagnosis of myocardial infarction and confirmed the diagnosis of pericarditis. Although the patient's outcome was uncomplicated, physicians are urged to consider the diagnosis of pericarditis before using thrombolytic therapy to avoid life-threatening complications.- - - - - - - - - - ranking = 1keywords = chest pain, chest, pain (Clic here for more details about this article) |
10/120. Acute myopericarditis after diphtheria, tetanus, and polio vaccination.We report the first case of myopericarditis after triple vaccination against diphtheria, tetanus, and poliovirus in a young adult. He presented with fever, acute chest pain, and diffuse ST-segment elevation 2 days after vaccination. Two-dimensional echocardiography findings were normal. Endomyocardial biopsy showed interstitial edema with diapedesis of erythrocytes. Laboratory findings showed inflammatory syndrome and elevated circulating immune complexes. He recovered within a few days with high-dose aspirin treatment and was without complications at 3-month follow-up. We discuss the different hypotheses for infective or hypersensitivity myocarditis.- - - - - - - - - - ranking = 1keywords = chest pain, chest, pain (Clic here for more details about this article) |
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